What is Trauma and Why Must We Address It?

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Creating Trauma Informed Systems of Care for
Human Service Settings

• What is Trauma and Why Must We Address It?

Joan Gillece, PhD National Center for Trauma
Informed Care
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What is Trauma?

• Definition (NASMHPD, 2006)
• The experience of violence and victimization
  including sexual abuse, physical abuse, severe
  neglect, loss, domestic violence and/or the
  witnessing of violence, terrorism or disasters
• DSM IV-TR (APA, 2000)
• Persons response involves intense fear, horror
  and helplessness
• Extreme stress that overwhelms the persons
  capacity to cope

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Definition of TraumaInformed Care

• Mental Health Treatment that incorporates
• An appreciation for the high prevalence of
  traumatic experiences in persons who receive
  mental health services
• A thorough understanding of the profound
  neurological, biological, psychological and
  social effects of trauma and violence on the
  individual
• (Jennings, 2004)

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Prevalence of TraumaMental Health Population
United States

• 90 of public mental health clients in have been
  exposed to trauma
• (Mueser et al., 2004, Mueser et al., 1998)
• 51-98 of public mental health clients in have
  been exposed to trauma
• (Goodman et al., 1997, Mueser et al., 1998)
• Most have multiple experiences of trauma
• (Mueser et al., 2004, Mueser et al., 1998)
• 97 of homeless women with SMI have experienced
  severe physical sexual abuse 87 experience
  this abuse both in childhood and adulthood
• (Goodman et al., 1997)

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Prevalence of TraumaChild Mental Health/Youth
Detention Population - U.S.

• Canadian study of 187 adolescents reported 42
  had PTSD
• American study of 100 adolescent inpatients 93
  had trauma histories and 32 had PTSD
• 70-90 incarcerated girls sexual, physical,
  emotional abuse
• (DOC, 1998, Chesney Sheldon, 1991)

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Prevalence of TraumaSubstance Abuse Population
U.S.

• Up to two-thirds of men and women in SA treatment
  report childhood abuse neglect (SAMSHA
  CSAT, 2000)
• Study of male veterans in SA inpatient unit
• 77 exposed to severe childhood trauma
• 58 history of lifetime PTSD (Triffleman et al.,
  1995)
• 50 of women in SA treatment have history of rape
  or incest
• (Governor's Commission on Sexual and Domestic
  Violence, Commonwealth of MA, 2006)

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Other Critical Trauma Correlates The
Relationship of Childhood Trauma to Adult Health

• Adverse Childhood Events (ACEs) have serious
  health consequences
• Adoption of health risk behaviors as coping
  mechanisms
• eating disorders, smoking, substance abuse, self
  harm, sexual promiscuity
• Severe medical conditions heart disease,
  pulmonary disease, liver disease, STDs, GYN
  cancer
• Early Death (Felitti et al., 1998)

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Adverse Childhood Experiences

• Recurrent and severe physical abuse
• Recurrent and severe emotional abuse
• Sexual abuse
• Growing up in household with
• Alcohol or drug user
• Member being imprisoned
• Mentally ill, chronically depressed, or
  institutionalized member
• Mother being treated violently
• Both biological parents absent
• Emotional or physical abuse
• (Fellitti et al, 1998)

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ACE Study

• Male child with an ACE score of 6 has a 4600
  increase in likelihood of later becoming an IV
  drug user when compared to a male child with an
  ACE score of 0. Might heroin be used for the
  relief of profound anguish dating back to
  childhood experiences? Might it be the best
  coping device that an individual can
  find? (Felitti et al, 1998)

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ACE Study

• Is drug abuse self-destructive or is it a
  desperate attempt at self-healing, albeit while
  accepting a significant future risk? (Felitt
  i, et al, 1998)

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ACE Study

• Addiction is best viewed as an understandable,
  unconscious, compulsive use of psychoactive
  materials in response to abnormal, prior life
  experiences, most of which are concealed by
  shame, secrecy, and social taboo. (Felitti
  et al, 1998)

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What does the prevalence data tell us?

• The majority of adults and children in
  psychiatric treatment settings have trauma
  histories
• A sizable percentage of people with substance use
  disorders have traumatic stress symptoms that
  interfere with achieving or maintaining sobriety
• A sizable percentage of adults and children in
  the prison or juvenile justice system have trauma
  histories
• (Hodas, 2004, Cusack et al., Mueser et al.,
  1998, Lipschitz et al., 1999, NASMHPD, 1998)

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What does the prevalence data tell us?

• Growing body of research on the relationship
  between victimization and later offending
• Many people with trauma histories have
  overlapping problems with mental health,
  addictions, physical health, and are victims or
  perpetrators of crime
• Victims of trauma are found across all systems of
  care
• (Hodas, 2004, Cusack et al., Muesar et al.,
  1998, Lipschitz et al., 1999, NASMHPD, 1998)

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Therefore

• We need to presume the clients we serve have a
  history of traumatic stress and exercise
  universal precautions by creating systems of
  care that are trauma-informed
• (Hodas, 2005)

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Trauma Informed Non Trauma Informed

• Recognition of high prevalence of trauma
• Recognition of primary and co-occurring trauma
  diagnoses
• Assess for traumatic histories symptoms
• Recognition of culture and practices that are
  re-traumatizing

• Lack of education on trauma prevalence
  universal precautions
• Over-diagnosis of Schizophrenia Bipolar D.,
  Conduct D. singular addictions
• Cursory or no trauma assessment
• Tradition of Toughness valued as best care
  approach

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Trauma Informed Non Trauma Informed

• Power/control minimized - constant attention to
  culture
• Caregivers/supporters collaboration
• Address training needs of staff to improve
  knowledge sensitivity

• Keys, security uniforms, staff demeanor, tone of
  voice
• Rule enforcers compliance
• Patient-blaming as fallback position without
  training

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Trauma Informed Non Trauma Informed

• Staff understand function of behavior (rage,
  repetition-compulsion, self-injury)
• Objective, neutral language
• Transparent systems open to outside parties

• Behavior seen as intentionally provocative
• Labeling language manipulative, needy,
  attention-seeking
• Closed system advocates discouraged

(Fallot Harris, 2002 Cook et al., 2002, Ford,
2003, Cusack et al., Jennings, 1998, Prescott,
2000)
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Trauma Informed Care

• Contact information
• Joan Gillece, PhD
• Joan.gillece_at_nasmhpd.org
• 703-739-9333